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3、分叉病变的介入治疗(候静波教授)


冠脉分叉病变的介入治疗
哈医大二院心血管病医院 侯静波

让我们先从一个病例开始……

病例资料
? 60岁男患;

? 发作性心前区疼痛6年,加重1个月
? 既往高血压病史,糖尿病史10年,最高血压

160/110mmHg;
? 长期吸烟史40年,无饮酒史; ? 入院时肝功肾功及相关化验检查基本正常。

病例资料
? 在外院行PCI治疗2次,第一次于前降支植入支架一

枚(09年10月),10年6月因有症状再行冠脉造影

发现为前降支、第一对角支真分叉病变,因冠脉钙
化较重,行IVUS检查后, 过程中造成前降支、对角

支急性闭塞,紧急于前降支植入支架,对角支未能
开通,患者PCI后反复有不稳定心绞痛发生,20天 后来我院。

外院造影结果

外院造影结果

外院PCI过程

外院PCI过程

试图恢复对角支血流未果

外院PCI过程

外院PCI过程

紧急于前降 支植入2枚

支架后

病例资料
? 患者因PCI后反复有不稳定心绞痛发生,较以往加

重,20天后来我院。

造影结果

造影结果

治疗策略
? 患者前降支有轻度重构,对角支闭塞,左冠提供对

角支少量的侧枝循环;
? 患者临床症状比较明显,但临床检查并无确切的缺

血证据,是否有进一步PCI,开通对角支的必要?

OCT检查
对角支开口处有 血栓,并无明显 钙化,可看到开 口缝隙

近端支架 贴壁尚可

对角支远段多层 支架

治疗策略
? 患者对角支血流不充分,且开口提示血栓性

病变,考虑还是上次PCI过程中急性损伤了
对角支开口所致,对角支应该还有打开的可 能,决定尝试PCI。

PCI过程

Feilder导丝未通过,Pilot 150导 丝进入对角支,1.5*15mm球囊

PCI过程

PCI过程

以类似provisional T支架技术及对吻扩 张植入对角支支架

术后情况
? 患者术后心绞痛消失,运动负荷试验阴性; ? 一个决定引发了冠脉急性闭塞,被动的急诊支 架植入及择期开通对角支虽然可恢复血流,但 患者局部支架多层,犬牙交错,远期效果还有 待评价……

分叉病变

Background: Bifurcation lesions
?15-20 % of lesions treated in the cathlab ?Still a challenge for interventionalists ?Lower success rates ?Higher incidence of procedural complications ?Higher reintervention rates ?Ideal strategy of bifurcation lesion treatment is still debated

Bifurcation Classification (Medina et al)

Classification

1 or 2 Stents :Randomized Trials
Study Pan et al Colombo et al NORDIC Ferenc et al. No. Pat- Two-stent Type of Thienopyridine ients Strategy DES duration, mo 91 85 413 202 Any Any Any T-stenting Crush or Culotte Crush SES SES SES SES 12 3 6-12 6-12 Intention to Treat Yes No Yes Yes Angio F/U (months) 6 6 8 9 Clincial F/U (months) 11 6 6 12, 24

BBC ONE
CACTUS

500
350

PES
SES

9
6

Yes
Yes


6

9
6, 12

Brar et al. EuroIntervention, 2009 (in-press)

Bifurcation Stenting Meta-Analysis
Mortality
Pan et al Colombo et al NORDIC Ferenc et al. BBC ONE CACTUS
Overall
0.01 0.1

Provisional

Two Stent

0.9% 0.7%
Relative Risk (95% CI)

1.12 (0.42-3.02)
P = 0.82

1

10

100

Favors Provisional Favors Two-Stent

Brar et al. EuroIntervention, 2009 (in-press)

Bifurcation Stenting Meta-Analysis
Myocardial Infarction
Pan et al Colombo et al NORDIC Ferenc et al. BBC ONE CACTUS
Overall
0.01 0.1

Provisional

Two Stent

3.6% 6.8%
Reduction

43%
Relative Risk (95% CI)

0.57 (0.37-0.87)
P = 0.01
1
10 100

Favors Provisional Favors Two-Stent

Brar et al. EuroIntervention, 2009 (in-press)

Bifurcation Stenting Meta-Analysis
Target Lesion Revascularization
Pan et al Colombo et al NORDIC Ferenc et al. BBC ONE CACTUS
Overall
0.01 0.1

Provisional

Two Stent

5.1% 5.4%
Relative Risk (95% CI)

0.91 (0.61-1.35)
P = 0.63

1

10

100

Favors Provisional Favors Two-Stent

Brar et al. EuroIntervention, 2009 (in-press)

Bifurcation Stenting Meta-Analysis
Main Branch Stenosis
Pan et al Colombo et al NORDIC Ferenc et al. CACTUS

Provisional

Two Stent

4.9% 3.6%
Relative Risk (95% CI)

1.41 (0.76-2.61)
P = 0.27

Overall
0.01 0.1

1

10

100

Favors Provisional Favors Two-Stent

Brar et al. EuroIntervention, 2009 (in-press)

Bifurcation Stenting Meta-Analysis
Side Branch Stenosis
Pan et al Colombo et al NORDIC Ferenc et al. CACTUS

Provisional

Two Stent

14.0% 13.3%
Relative Risk (95% CI)

1.09 (0.79-1.51)
P = 0.60

Overall
0.01 0.1

1

10

100

Favors Provisional Favors Two-Stent

Brar et al. EuroIntervention, 2009 (in-press)

Bifurcation Stenting Meta-Analysis
Stent Thrombosis
Pan et al Colombo et al NORDIC Ferenc et al. BBC ONE CACTUS
Overall
0.01 0.1

Provisional

Two Stent

0.8% 1.7%
Relative Risk (95% CI)

0.56 (0.23-1.51)
P = 0.45

1

10

100

Favors Provisional Favors Two-Stent

Brar et al. EuroIntervention, 2009 (in-press)

Bifurcation Stenting Meta-Analysis
QCA Analysis – Percent Diameter Stenosis
(difference in means)
Main Branch
Pan et al Colombo et al NORDIC Ferenc et al. CACTUS Pan et al Colombo et al NORDIC Ferenc et al. CACTUS

Side Branch

-1.08 (-2.91- 0.74)
Overall
-20 -10 1 10 20

1.30 (-23.35 - 5.96)

Overall
-20 -10 1 10 20

Favors Provisional Favors Two-Stent

Favors Provisional Favors Two-Stent

Brar et al. EuroIntervention, 2009 (in-press)

没有过多的分叉处病变
There is no too much Bifurcation lesion.
? 分叉病变处理的必要性 :分支大小、分布、是 否梗塞支、有无侧支循 环
? 分叉病变处理的可行性 :分支直径、成角情况

How Often We Need 2nd Stent after MV Stent? Crossover from 1 Stent to 2 Stents
40.0% 35.0% 30.0% 25.0% 20.0% 15.0% 10.0% 5.0% 0.0% NO R D IC BBK C AC T US B B C O NE 4.3% 9.4% 2.8% 19.2% 18.8% 14.7%
TVF due to SB restenosis 2.8% (no angio f-up) NA

C ros s ov er from 1 s tent to 2 s tents 31.0%

Ang iog raphic S B res tenos is

Steigen TK et al. Circulation. 2006;114:1955-1961 Ferenc M et al. Eur Heart J 2008; 29: 2859–2867 Colombo A et al. Circulation. 2009;119:71–78 HildickSmith D et al. Circulation. 2010;121:1235-1243

I N S I D E

II

T r i a l

Pts Randomized to 1 Stent: Predictors of Cross-Over to SB Stenting
VARIABLE
QCA Lesion length, mm Reference diameter % DS IVUS MLA, mm2 Plaque burden Remodeling index Calcium (arc >90O ), %

YES

NO

P value
0.01 0.83 0.02 0.005 0.41 0.03 0.006

13.9 2.47 88.6 1.73 65.5 0.65 83.3

8.87 2.51 71.7 2.33 59.1 0.96 29.3

U n f a v o u r a
bl e

a n g l e

Unfavourable angle

Unfavourable angle: mini crush

F i n a l

True Bifurcation
(significant stenosis on the main and side branches) No Provisional SB stenting No Yes Is SB suitable for stenting? Yes

Stent on MB “Keep It Open” for SB No

SB disease is diffuse &/or not localized to within 3 mm from the ostium? Yes

Provisional SB stenting

Elective implantation of two stents (MB and SB)

Correlation Between FFR and % Stenosis (QCA) in Jailed Side Branches
There was a negative correlation between the percent stenosis and FFR (r=0.41, p<0.001). No lesion with <75% stenosis had FFR<0.75. Among 73 lesions with ≥75% stenosis, only 20 lesions were functionally significant.

FFR measurements demonstrate that most of stenotic SB do not have functional significance
Koo BK et al J Am Coll Cardiol 2005;46:633–7)

不打无准备之仗
God only blesses prepared mind. ? 病人—器械—医生 ? 注重器械选择: 指引导管 导丝 球囊及支架

Why Wire Both Branches?

? Protects SB from closure due to plaque shift and/or stent struts during MB stenting ? Jailed SB wire facilitates re-wiring of the SB: ? widening the angle between the MB and SB ? by acting as a marker for the SB ostium if SB occludes ? changing the angle of SB take-off

? CAUTION WHEN REMOVING JAILED WIRES!

Why Protect SB’s from Closure?
? Occlusion of SB’s >1mm associated with 14% incidence of Myocardial Infarction
Arora RR et al. Cathet Cardiovasc Diagn 1989;18:210-2.

? SB closure associated with large periprocedural MI
Chaudhry EC et al. J Thromb Thrombolysis 2007.

Keep It Open (KIO)
When the SB has ostial or diffuse disease AND when the SB is not suitable (too small) for stenting or clinically not relevant
? 6 Fr guiding catheter 1. Wire both branches 2. Dilate MB if needed 3. Stent MB and leave wire in the SB 4. Post-dilatation of MB with jailed wire in SB

Do not re-wire SB or postdilate or predilate SB

Provisional
When SB has minimal disease or only at the ostium AND when SB is suitable for stenting ? 6 Fr or 7F guiding catheter
1. Wire both branches

2.
3.

Dilate MB and SB if needed
Stent MB leaving a wire in the SB
wire(Prowater/

? Re-wire SB and then remove jailed
wire)

Rinato, BMW,Runthrough,intermediate wire,Pilot 50 or 150 ,feilder

? Kissing balloon inflation ? Stent SB only if suboptimal result (TAP, reverse crush, culotte)

Two Stents
When SB has disease extending beyond its ostium AND when SB is suitable for stenting

? 7 Fr guiding catheter
1. Wire both branches

2. Dilate MB and SB if needed
3. Perform crush, culotte or V-stent 4. If crush: rewire SB and perform high pressure SB dilatation (2-step kiss) 5. Final kissing balloon inflation always!

2-Step Kiss
No Kiss One-step Kiss Two-step Kiss

A

B

C

Slide courtesy of John Ormiston

Optimal Performance of 2 Stent Techniques Important in Reducing Event Rates

Impact of learning curve in Technique; TCT 2006

An approach for bifurcational lesions when using 2 stents as intention to treat
Bifurcational lesion with no disease proximal to the bifurcation or very short left main Bifurcational lesion with main branch disease extending proximal to the bifurcation and side branch which has origin with about 90° angle Bifurcational lesion with main branch disease extending proximal to the bifurcation and side branch which ha origin with about 60° angle

V-Stent

T-Stent

Short-Mini Crush

Pre

Post

Pre

Post

Pre

Post

Cross Section

The T-stenting with Protrusion Technique (TAP) as a Cross-over from the Provisional Approach

Step 1:

Wire both branches and predilate the main and the side branch as required.

Stent the MB jailing the SB wire

Step 2:

If the result in SB unsatisfactory due to plaque shift or dissection and SB has to be stented, then re-cross into the SB through the MB stent struts

The T-stenting with Protrusion Technique (TAP) as a Cross-over from the Provisional Approach
Position stent in SB ensuring coverage of ostium with minimal protrusion into MB and place noncompliant balloon in MB stent

Step 3:

Step 4:

Inflate the delivery balloon in the SB and the MB balloon simultaneously

Final Result:

T stenting

A
1: Wire both branches and predilate if needed

2: Stent the MB leaving a wire in the SB. The stent in the MB can be deployed at high pressure

T stenting

B
3: Rewire the SB passing through the struts of the MB stent, remove the jailed wire and dilate toward SB

Assuming that the result is suboptimal

4: Advance stent into the SB with no MB protrusion and deploy the stent

T stenting

C

5: Perform final kissing inflation following advancement of a balloon in the MB. If needed use a new balloon for the SB

Crush stenting

A
1: Wire both branches and predilate if needed

2 : Advance the 2 stents. MB stent positioned proximally. The SB stent will protrude only minimally into MB

Crush stenting

B
3: Deploy the SB stent

4: Check for optimal result in the SB and then remove balloon and wire from SB. Deploy the MB stent

Crush stenting

C
5: Rewire the SB and perform high pressure dilatation

6: Perform kissing balloon inflation

Culotte stenting

A
1: Wire both branches and predilate if needed

2: Remove from or leave the wire in the more straight branch (MB) and deploy a stent in the more angulated branch (SB)

Culotte stenting

B
3: Remove the wire from the stented branch and cross with a wire and balloon into the of the unstented branch and dilate (MB).

4: Place a second stent into the unstented branch (MB) and expand the stent leaving some proximal overlap

Culotte stenting

C

5: Cross with a wire the first stent (SB) and perform kissing balloon inflation.

Reverse crush stenting

A
1: Wire both branches and predilate if needed

2: Leave a wire in the SB and deploy a stent in the MB.

Reverse crush stenting

B
3: Rewire side branch and advance a balloon and dilate toward SB

EVALUATE RESULT: if the result is not acceptable then

4: Position a stent in the SB with minimal protrusion in the MB. Leave a balloon in the MB

Reverse crush stenting

C
5: Deploy the stent in the SB and remove the wire and the balloon

6: Crush the short protruding part of SB stent over the stent in MB by inflating the MB balloon

Reverse crush stenting

D
7: Rewire the SB and perform high pressure dilatation

8: Perform final kissing balloon inflation

V stenting

A
1: Wire both branches and predilate if needed

2: Position two parallel stents covering both branches and extending into the main branch V: minimal protrusion into MB SKS: double barrel into the MB

V stenting

B
3: Deploy one stent

4: Deploy the second stent

Some operators deploy the two stents simultaneously

V stenting

C
5: Perform high pressure single stent postdilatation and medium pressure kissing inflation with short and noncompliant balloons

Dedicated Bifurcation Stents
? Stents that facilitate provisional SB stenting and maintain direct access to the SB after MV stenting; Preformed MV stent with side ports to facilitate access to the SB (Antares, Invatec Twin-rail, Multi-Link Frontier, Nile Croco, Petal, SLKview, StenTys, Y-Med Side-Kick) ? Stents designed to treat the SB first; Second stent is required for the main branch (Sideguard, Tryton) ? Conical stents for the geometry of the ostium; These may require additional stents to be implanted in the main branch or side branch (Axxess)
Garg S, Serruys PW. J. Am. Coll. Cardiol. 2010;56;S43-S78

Currently Available Dedicated Stents

Garg S, Serruys PW. J. Am. Coll. Cardiol. 2010;56;S43-S78

Currently Available Dedicated Stents

Garg S, Serruys PW. J. Am. Coll. Cardiol. 2010;56;S43-S78

DIVERGE study
N=302 AXXESS stent: sef expanding nitinol alloy, drug biolimus A9, carier: bioabsorbable PLA polymer

Verheye S et al. J Am CollCardiol

SIDEGUARD I & II
IVUS analysis of Sideguard I (N=11)

Cappella Sideguard stent area at the carina of the SB increased from 3.9±1.2 to 4.6 ± 1.1 mm2 (p= 0.04).
Grube E. ANGIOPLASTY SUMMIT-TCTAP 2010 Doi H et al. Am J Cardiol 2009;104:1216 –1221

Tryton I, FIM study
N=30 Tryton in SB + DES in MV 6M clinical + angio f-up

Onuma Y et al. EuroInterv 2008;3:546-552

战略上
? 尽可能的“不处理” ? 尽可能的“简单”

战术上
? 尽可能“Active” ? 尽可能“Kissing” ? 尽可能“DES”



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